Tips for Approaching Clinical Documentation Improvement

December 11, 2015 - Clinical documentation is an important bridge between healthcare coders and physicians. The accurate documentation of health services provided benefits healthcare organizations not only with regard to revenue cycle, but with accurate care delivery and population health management.

However, sometimes there is a disconnect between coders and physicians, creating a challenge when it comes to accurate clinical documentation. Clinical documentation improvement is an important endeavor for healthcare organizations to make in order to ensure accurate clinical documentation.

However, how do organizations approach clinical documentation improvement? And what are the best practices for clinical documentation? Below, we seek to answer those questions and highlight some best methods for clinical documentation improvement.

“When it comes to documenting clinical encounters, providers are expected to provide legible, complete, clear, consistent, precise, and reliable documentation of a patient’s health history, present illness, and course of treatment,” AHIMA explains. “This documentation includes observations, evidence of medical decision making in determining a diagnosis, treatment plan, and outcomes of all tests, procedures, and treatments.”

Coders and clinical documentation specialists improve the process by helping physicians and other providers refine coding information. According to AHIMA, clinical documentation specialists do the following:

Facilitating and obtaining appropriate provider documentation within the health record for clinical conditions and treatment required for accurate representation of severity of illness, expected risk of mortality, and complexity of care of the patient

Exhibiting thorough knowledge of clinical documentation requirements as they relate to the classification systems, MS-DRG assignment, and clinical conditions and treatment needs of the patient population

Educating members of the patient care team and others regarding documentation guidelines

Several hospitals see clinical documentation improvement by improving at small increments. This was the method for the staff at Summit Healthcare Regional Medical Center, which saved approximately $550 thousand in one year.

In an initiative spearheaded by Mandy Rogers, RN, and her nursing team, the staff at the hospital significantly improved its clinical documentation by focusing on small details and basic queries.

“One of the things that we hit pretty hard at first was what changes to the documentation were going to change our DRGs,” Rogers explained explained to HealthITAnalytics.com in a past interview. “What was going to get us a major complicating condition (MCC)? We focused on those things and really just did the rudimentary queries about things like pneumonia. What kind is it? That changes your DRG this way or that way. So, we really just focused on that.”

This method helped the staff make small, incremental improvements, eventually creating one large improvement overall.

“We told the doctors, ‘Pay attention to the queries when you’re answering them, because this will tell you what you need to document next time. And then you won’t get a query.’ We also worked a lot with our coders about what they saw on the back end: things we could try to change on the front end of things and try to catch before it gets to the coders,” Rogers said.

Remote work has helped Baystate coders achieve better accuracy and efficiency. While coders are still able to send queries to physicians remotely via mobile technologies, efficiency improves due to fewer interruptions.

Because physicians are able to better concentrate on patients without the burden of coders physically coming to them with queries, efficiency as well as patient care has improved.

“We don’t interrupt the productivity of our individuals by having them pair or mentor off another individual, but we use these tools to understand where the variations lie and where there’s other opportunities,” Jennifer Cavagnac, CCDS, Assistant Director of Clinical Documentation Improvement at Baystate Health, told the Journal of AHIMA.

Between the recent implementation of the ICD-10 code set, as well as the increasing emphasis on public health reporting and population health management, clinical documentation improvement projects are sure to remain of considerable relevance or providers. As health technologies evolve and improve, it is clear the process for clinical documentation improvement will as well.